The Sagging Brow

Need a Lift?

Do friends sometimes think you’re angry, or tell you to smile?
There is a cure for that furrowed brow that some of us develop with
age: it’s called a brow lift. “Many people, when they hear ‘brow
lift,’ think of an overdone, startled look, so I call it ‘brow
shaping,’ ” says Dr. Michael Nayak of Nayak Plastic Surgery. Brow
lifts are done to raise the brow, not to get rid of crows’ feet or
the creases between the eyebrows, he explains. It can help those
lines, because during the procedure the muscles that cause them are
removed, but they’re not the main target. If, when you raise your
brow manually, excess skin above the eyes disappears, only a brow
lift is needed.

Some people, however, still have excess skin on the upper
lids after the lift, and still others have a brow in the correct
position, but need the eyelids done. The aim is to have a
nice-looking brow and eye complex that looks youthful and rested.
The surprised look people fear from a brow lift results when the
inner part of the brow is incorrectly raised higher than the outer
edges, Nayak explains.

There are several different approaches to brow lifts,
depending on the hairline and head shape of the individual, he
says. “People with a short forehead or low hairline usually need an
endoscopic lift with several very short incisions,” Nayak says.
“Bald men do well with the endoscopic lift because the tiny
incisions aren’t noticeable. People with a high, rounded forehead
generally already wear bangs to camouflage the height. For them, I
would probably favor an open incision right at the hairline. When
it’s done well, the hair grows back through the incision and it can
shorten the forehead to bring the face into better balance.”

The other type of brow lift he sometimes does, particularly
for older people with droopiness at the outsides of the brow that
may impact their vision, is the direct brow lift, which requires an
incision over the outside half of each eyebrow. Older, thinner skin
heals well, and the procedure is often covered by insurance.

Dr. Marissa Tenenbaum of West County Plastic Surgeons of
Washington University says people don’t often consider a brow lift
when their eyelids droop because they have gotten into the habit of
raising their brow to compensate. “When they come in, I lay my hand
on their brow to get it to relax and see where the brow sits
without that raising,” she says. “If it droops below the
superorbital ridge, it needs lifting.” Often, a patient will need
both a forehead lift and some upper eyelid work, Tenenbaum notes,
but she is very careful not to overlift the brow.

She also reports using Botox to give a chemical lift by
arresting the muscles at the outsides of the brow that pull it
down, allowing the lifting muscles to do their job, and between the
eyebrows for the vertical wrinkles.

Dr. Samer Cabbabe of Cabbabe Plastic Surgery says three
types of brow lifts are popular today. The conventional ‘open brow
lift’ is one incision across the top of the forehead along the
hairline. Through it, the muscle can be tightened and excess skin
removed. Cabbabe says this method is the one most likely to cause
scalp numbness.

The brow lift he prefers is the endoscopic lift. “I use
three small incisions through which I lift the skin and tissue off
the forehead bone and weaken the muscles that depress the brow so
the muscles that lift can work unopposed,” Cabbabe explains.
“People do not look surprised.” He also does small brow lifts at
the temples for women who have droop only at the outsides of their
brow.

Cabbabe says some surgeons put hooks and internal fixation
screws under the tissue to anchor it, but he calls that unnecessary
if the lift is done right. And the hardware can erode through,
causing pain and tenderness, he adds. Many who need upper eyelid
surgery also will need a brow lift, he maintains. “I’ve seen people
who have had their upper eyelids done but the brow wasn’t
addressed,” he says. “And because they had extra eyelid skin, they
raised their eyebrows to keep their eyes open. But once that skin
was removed with surgery, they relaxed the brow and it
drooped.”

The entire face must be treated as a unit, Cabbabe says.
“When I treat faces, I look at the brow, face and neck,” he says.
“If people come in for a face lift, there’s a good chance they need
the brow lifted as well. If they want a neck lift, the neck can be
nice and tight, but the rest of the face still droops. It has to be
a total concept.”